Free Multi Dimensional Care practice for Multi Dimensional Care | Rasmusson (ATI RN). Answer 77 nursing exam-style questions with rationales, exam mode, and pro
A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?
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Explanation:
Assessing the radial pulse checks for adequate circulation and potential complications.
What soft tissue musculoskeletal injury is excessive stretching of a ligament?
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Explanation:
A sprain is an injury involving excessive stretching of a ligament.
A client has cellulitis on his left arm. What statement by the client indicates understanding of symptom management?
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Explanation:
What is an example of proper body mechanics when lifting?
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Explanation:
Proper body mechanics include holding objects close to the body to prevent injury.
A client has an open wound with creamy thick yellow drainage. How would the nurse document this finding?
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Explanation:
The client with rheumatoid arthritis is having her rheumatoid factor (RF) drawn while she is having a flare-up of the disease. Which result is seen in clients with rheumatoid arthritis?
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Explanation:
A client who is sitting in High-Fowler's position is at risk for what type of injury as the skin layers shift in opposite directions?
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Explanation:
What is a classic symptom assessed in clients with lupus?
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Explanation:
What steps are NOT included in preparing a sterile field?
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Explanation:
The following client come to the ophthalmology clinic. Which client needs to be seen first?
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Explanation:
Worsening vision after cataract surgery requires immediate attention to prevent complications.
What is correct about a nursing diagnosis?
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Explanation:
A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.
Which assessment is NOT a nonverbal sing of pain?
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Explanation:
The nurse assesses a wound with exudate. What should not be included when documenting the exudate?
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Explanation:
A client is in skeletal traction. With the nurse's assessment, it is noted that the pairs appear red, swollen and there is purulent drainage. What action does the nurse take first?
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Explanation:
What is not a nursing intervention for a client with osteoporosis?
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Explanation:
The correct answer is C. Avoiding muscle strengthening exercises is not recommended for clients with osteoporosis; on the contrary, weight-bearing exercises are beneficial. Choice A is correct as ensuring adequate calcium and vitamin D intake is essential for bone health. Choice B is also correct as weight-bearing exercises help improve bone density. Choice D is incorrect because avoiding repetitive movements is not a standard nursing intervention for osteoporosis.
The provider orders the client to be placed in a high-Fowler's position. At what angle will the nurse position the client?
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Explanation:
The correct answer is C: 90 degrees. In a high-Fowler's position, the client's head of the bed is raised to a 90-degree angle. This positioning helps improve breathing and facilitates eating and talking. Choice A, 15 degrees, is incorrect as it is not high enough to be considered a high-Fowler's position. Choice B, 0 degrees, is incorrect as it represents a flat or supine position. Choice D, 30 degrees, is also incorrect as it does not meet the criteria for a high-Fowler's position.
A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?
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Explanation:
A nurse is teaching a client who has a new prescription for ibuprofen to treat rheumatoid arthritis. The nurse should teach the client to monitor for what adverse effect of this medication?
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Explanation:
A nurse is teaching a client how to follow a low-purine diet as prescribed by the provider for the management of gout. What statement by the client indicates a correct understanding of the teaching?
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Explanation:
What phase of wound healing occurs at the time of injury and lasts about 3-5 days?
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Explanation:
A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?
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Explanation:
A nurse assesses an area of skin over a bony prominence. What finding would be most concerning?
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Explanation:
The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks how this can happen. What is the best response by the nurse?
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Explanation:
A client is diagnosed with systemic sclerosis (scleroderma). What symptoms is the first to occur?
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Explanation:
A well-rounded fitness program focuses on flexibility, resistance training and aerobic conditioning. What statements are true about a well-rounded fitness program? (Select all that apply)
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Explanation:
Resistance training, proper stretching, and exercise duration/intensity contribute to a well-rounded fitness program.
A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale, cool and swollen. What action does the nurse take next?
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Explanation:
The client states, "Why am I getting protein supplements while I am healing from a bed sore?"? What is the best response by the nurse?
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Explanation:
The nurse is providing education to a client regarding the administration of eye drops. Which of the following actions indicates the need for further client education?
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Explanation:
A client does not understand why vision loss due to glaucoma is irreversible. What is the best explanation?
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Explanation:
The correct answer is C. In glaucoma, the optic nerve damage due to high intraocular pressure leads to permanent vision loss because the nerve fibers do not regenerate. Choice A is incorrect as it discusses bacterial infection, not relevant to glaucoma. Choice B is incorrect because it refers to retinal detachment, not glaucoma. Choice D is incorrect because not all glaucoma cases lead to permanent blindness; vision loss can be prevented or slowed with treatment.
A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?
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Explanation:
What can the nurse NOT teach a client with acquired immunodeficiency syndrome (AIDS) to reduce the risk of infection?
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Explanation:
The nurse is providing medication for a client with osteomyelitis. What teaching should the nurse indicate in the education?
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Explanation:
Why is traction used?
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Explanation:
Traction is used to help align the bones properly during the healing process. Choice A is correct because traction assists in allowing the bones to realign correctly, promoting proper healing. Choice B is incorrect as traction does not decrease the risk of misalignment; instead, it helps reduce misalignment by aiding in bone alignment. Choice C is incorrect because while traction indirectly supports wound healing by ensuring proper bone alignment, its primary purpose is not wound healing. Choice D is incorrect as the primary purpose of traction is not to allow the client to rest longer, but rather to aid in bone alignment for optimal healing.
The nurse is preparing to administer medications to a client with osteoarthritis. What is the goal of medication therapy?
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Explanation:
What is the priority nursing diagnosis for a client with metastatic bone disease?
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Explanation:
The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.
What should the nurse do first if they are stuck by a needle?
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Explanation:
A nurse is teaching a client who has out about dietary recommendations. The nurse should teach the client which of the following beverages can trigger an attack?
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Explanation:
What are signs of hearing loss? (Select all that apply)
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Explanation:
Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.
The mother of a newborn baby is concerned that the baby will develop illnesses from being around people from outside of their family. What is the nurse's best response?
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Explanation:
A nurse is admitting a client who has tuberculosis. What transmission-based precautions should the nurse initiate?
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Explanation:
The nurses assess the client's pain prior to completing a dressing change. The client says his current pain is 5/10, but he has pain of 10/10 when his dressing is changed. What is the priority intervention for this client?
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Explanation:
The nurse notices a new area of skin breakdown near the site of a dressing. This would be an example of which phase of the nursing process?
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Explanation:
What is true about antiretroviral drugs used to treat human immunodeficiency virus (HIV)?
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Explanation:
The correct answer is that antiretroviral drugs inhibit viral replication. These medications work by interfering with the ability of the HIV virus to multiply in the body, helping to control the infection. Choice A is incorrect because consistency in taking antiretroviral drugs is crucial to their effectiveness. Missing doses can lead to treatment failure and the development of drug-resistant strains of HIV. Choice B is incorrect as there are multiple licensed drugs that are effective in treating HIV. Choice D is also incorrect as antiretroviral drugs do not kill the virus but rather suppress its replication.
The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?
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Explanation:
Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.
What is the condition called when the client's pupils are different sizes and have been this way since childhood?
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Explanation:
Anisocoria is the correct answer. Anisocoria is the condition of having pupils of different sizes. Exophthalmos refers to abnormal protrusion of the eyeball, not pupil size difference. Strabismus is a condition where the eyes are not properly aligned with each other. Scleral edema is swelling of the sclera, the white part of the eye, and not related to differing pupil sizes.
A nurse is caring for a 25-year-old male quadriplegic client. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?
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Explanation:
The correct answer is to provide passive range of motion (ROM). In quadriplegic clients, who have limited or no movement of their limbs, passive ROM exercises are crucial to maintain joint mobility and prevent joint contractures. Administering glucosamine supplements (choice A) is not directly related to promoting joint mobility. Turning the client every 2 hours (choice B) is essential for preventing pressure ulcers but does not directly address joint contracture and mobility. Providing active ROM exercises (choice C) may not be suitable for quadriplegic clients as they are unable to perform these movements on their own.
What is the likely reason that a client with acquired immunodeficiency syndrome (AIDS) would succumb to pneumonia while a healthy person exposed to the same infection did not?
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Explanation:
A client has sustained an open fracture. What nursing intervention will best prevent osteomyelitis in this client?
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Explanation:
Proper hand hygiene is crucial in preventing infections such as osteomyelitis in clients with open fractures. Keeping the hands clean helps reduce the risk of introducing harmful pathogens to the wound site. Delegating all client personal care to specific unlicensed assistive personnel (Choice A) is not appropriate as direct involvement in wound care is essential in preventing infections. Placing the client in contact precautions (Choice B) is not directly related to preventing osteomyelitis in this context. Administering pain medication (Choice D) is important for managing the client's pain but does not directly address the prevention of osteomyelitis.
Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?
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Explanation:
What is not a potential complication of RA?
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Explanation:
A nurse is assessing a client with hallux valgus. What is another term for this assessment finding?
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Explanation:
Hallux valgus is commonly known as a bunion, which is a bony bump that forms on the joint at the base of the big toe. A) Thoracic deformity is unrelated to hallux valgus. C) A corn is a thickened area of skin on the foot, not synonymous with hallux valgus. D) Metacarpal involvement refers to the hand, not the foot where hallux valgus occurs.
What is the term for a ringing in the ears reported by the client?
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Explanation:
Tinnitus is the correct answer. Tinnitus refers to the perception of noise or ringing in the ears. This condition can be constant or intermittent and may be caused by various factors such as exposure to loud noises, ear infections, or underlying health conditions. Choices A, B, and C are incorrect as Weber and Rinne tests are related to hearing assessment, while the pinna is the external part of the ear responsible for collecting sound waves.
What is not appropriate client education on the preventing the spread of methicillin- resistance Staphylococcus aureus (MRSA)?
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Explanation:
A nurse is preparing a community presentation about repetitive motion injuries. Which of the following occupations should the nurse identify as increasing a client's risk for carpal tunnel syndrome?
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Explanation:
What complication of fractures is caused by increased pressure which can result in decreased circulation to the area?
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Explanation:
Acute compartment syndrome is the correct answer. It involves increased pressure within muscles, leading to decreased blood flow and tissue damage. Venous thromboembolism (Choice A) is a condition where a blood clot forms in a vein, usually in the leg. Fat embolism syndrome (Choice C) occurs when fat globules enter the bloodstream and block blood vessels. Hemorrhage (Choice D) refers to bleeding, which can occur with fractures but does not specifically involve increased pressure leading to decreased circulation as in acute compartment syndrome.
What is the priority nursing diagnosis after surgery to repair a fracture?
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Explanation:
The correct answer is B: Risk for infection. After surgery to repair a fracture, the priority nursing diagnosis is to monitor for the risk of infection to promote proper healing. Infections can significantly delay the healing process and lead to further complications. Choices A, C, and D are not the priority immediately post-surgery. Disturbed body image, risk for impaired skin integrity, and acute pain may be concerns but are not the priority in the immediate post-operative period following fracture repair.
What nursing intervention is best to improve communication with a hearingimpaired client?
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Explanation:
How many mg is 5000 mcg? (Type answer as numeric only)
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Explanation:
5000 mcg is equal to 5 mg.
Which among the following is NOT the cause of pressure ulcers?
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Explanation:
A client recently had an above the knee amputation and complains of pain distal to the amputation. What type of pain is the client experiencing?
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Explanation:
A goal for a client with impaired mobility is to prevent skin breakdown. What nursing intervention would best help the client meet this goal?
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Explanation:
A client with lupus experience Raynaud's phenomenon. What should the nurse include when providing client education about this?
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Explanation:
Which of the following lab tests should NOT be used for diagnosing connective tissue diseases?
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Explanation:
Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?
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Explanation:
The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.
A client arrives speaking only Spanish. What is the priority nursing intervention?
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Explanation:
The client with RA complains of intensely dry eyes. What does the nurse suspect?
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Explanation:
Convert 30 ml to ounces. (Type the answer as numeric only)
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Explanation:
30 ml is equivalent to 1 ounce.
A client with chronic osteomyelitis is being discharged from the hospital. What is the nurse's priority discharge intervention?
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Explanation:
The correct answer is C: Teaching adherence to the antibiotic regimen. In chronic osteomyelitis, the priority is to ensure proper treatment of the infection, which heavily relies on consistent adherence to the prescribed antibiotic regimen. This helps in eradicating the infectious organisms and preventing recurrence. Choices A, B, and D are important aspects of care but teaching adherence to the antibiotic regimen takes precedence as it directly impacts the successful management of chronic osteomyelitis.
A client has a new arm cast. What is incorrect teaching by the nurse?
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Explanation:
Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.
A client has a new arm cast. What is incorrect teaching by the nurse?
Select the best answer.
Explanation:
Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.
A client with a bone cancer states that he is in too much pain to walk today. What should the nurse do first?
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Explanation:
Assessing the pain characteristics helps in managing the client's pain effectively.
What finding is often present in a client with osteoporosis?
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Explanation:
Kyphosis is a common finding in osteoporosis due to vertebral compression fractures. Chronic pain (Choice A) can occur in osteoporosis but is not a specific finding. Dupuytren's contracture (Choice B) is a condition affecting hand fingers' connective tissue, not typically associated with osteoporosis. Inflammation (Choice C) is not a typical finding in osteoporosis but rather a characteristic of other conditions.
A client with chronic osteomyelitis is being discharged from the hospital. What is the nurse's priority discharge intervention?
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Explanation:
The correct answer is C: Teaching adherence to the antibiotic regimen. In chronic osteomyelitis, the priority is to ensure proper treatment of the infection, which heavily relies on consistent adherence to the prescribed antibiotic regimen. This helps in eradicating the infectious organisms and preventing recurrence. Choices A, B, and D are important aspects of care but teaching adherence to the antibiotic regimen takes precedence as it directly impacts the successful management of chronic osteomyelitis.
A client has a new arm cast. What is incorrect teaching by the nurse?
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Explanation:
Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.
A client has a new arm cast. What is incorrect teaching by the nurse?
Select the best answer.
Explanation:
Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.
A client with a bone cancer states that he is in too much pain to walk today. What should the nurse do first?
Select the best answer.
Explanation:
Assessing the pain characteristics helps in managing the client's pain effectively.
What finding is often present in a client with osteoporosis?
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Explanation:
Kyphosis is a common finding in osteoporosis due to vertebral compression fractures. Chronic pain (Choice A) can occur in osteoporosis but is not a specific finding. Dupuytren's contracture (Choice B) is a condition affecting hand fingers' connective tissue, not typically associated with osteoporosis. Inflammation (Choice C) is not a typical finding in osteoporosis but rather a characteristic of other conditions.
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